This is one in a series of blogs addressing the most common questions we receive regarding workers' compensation in California. It is not meant to be legal advice nor does the information provided here apply to all situations. For information on your particular case, you should contact an attorney.
What is independent medical review (IMR) and how do I get one?
This is a question we get asked very frequently. The most common independent medical review, or IMR, is part of the dispute resolution process when utilization review (UR) performed by the insurance company or employer (for our purposes, we will refer to both as the insurance company from here on out) denies the medical care recommended for you by your doctor. [The process of UR is discussed in further detail in an earlier blog entry.] In the lingo of workers' compensation, this is generally referred to as 'IMR', but more accurately is 'UR-IMR', to differentiate it from the other IMR process allowed under California law.
There are two types of IMR in California workers' compensation. There is an IMR process as established under California law referred to as UR-IMR (Labor Code §§ 4610.5 and 4610.6). There is also another IMR established under California law that is available to injured workers for disputes when the injured worker is treating in a Medical Provider Network ('MPN'), referred to as MPN-IMR (Labor Code § 4616.4). [Medical provider networks are a group of doctors that the insurance company hand selects to treat injured workers who have an injury on the job, similar to an HMO. With very limited exceptions, the injured worker is required to treat with doctors within the insurance company's MPN.] However, this article will focus solely on UR-IMR because it is the more commonly used process.
The UR-IMR process was made into law by the California legislature in 2013. As of July 1, 2013, it applies to all injured workers - regardless of whether they were injured in 1980 or 2013.
Here is how the UR-IMR process generally works:
When you receive a UR denial or modification of the medical care your doctor has recommended for you, included with the UR denial or modification from the insurance company is a document entitled 'Application for Independent Medical Review.' The form is to be completely filled out by the insurance company so that all that is required from you is to sign it and send it in. This application for IMR must be filed within 30 days of the date of the UR denial or modification. The application is to be mailed or faxed to 'Maximus' - a company contracted by the State of California to perform UR-IMRs. The fax number and address to send the application for IMR are included on the form. You must also send a copy of the application for IMR that you file with Maximus to the insurance company.
Upon receipt of the application requesting an IMR, the state of California is to "expeditiously" review the request to determine if it is appropriate for IMR and then send the application to Maximus to assign a physician to perform the IMR. [Note that this review can take up to 30 days - so much for "expeditious!"] When Maximus has finally assigned a doctor to the case, you and the insurance company will receive a document called a Notice of Assignment and Request For Information ('NOAFRI' or 'NARI'). Within 15 days of receipt of the NARI, the insurance company is required to send all documents relevant to this medical treatment request in dispute to Maximus. You, your doctor and your attorney - should you have one - also have the option to send documents to Maximus in support of the medical treatment requested by your doctor. After receipt of the medical documents, Maximus has 30 days to make a decision.
The IMR doctor is required to hold an M.D. or D.O. degree and a current certification by a recognized American medical specialty board in the area or areas appropriate to the condition or medical treatment request under review - for instance, a podiatrist can review a request for a procedure on the foot, but should not review a request for brain surgery. The IMR doctor is to make the decision upon review of the document, and that decision must be consistent with treatment guidelines developed by the State of California - or, if the guidelines do not address the medical treatment requested, other evidence-based medical guidelines. The decision is to be written in simple, understandable terms that reference the medical guidelines followed in agreeing or disagreeing with the UR decision to deny or modify the medical treatment requested. Once the decision is made by the IMR doctor, it is to be sent to you, your doctor, your lawyer (if you have one) and the insurance company.
One glaring omission from this step 3 is that the IMR doctor does not examine you. In fact, the IMR doctor will be, as a matter of law, totally anonymous! You will never be given the right to find out who the IMR doctor is, let alone ask him or her any questions about the decision. You will only be told in which state the doctor has a medical license and the area of medical specialty the doctor practices in.
In short, the final decision on whether or not you get the medical care that your doctor [and remember, this is a doctor picked by the insurance company to treat you] recommended for you will be made by a nameless, faceless, totally anonymous doctor who does not even pick up the phone and call you to ask how you are feeling or what symptoms you are having. We wonder if the legislators who passed this law would be willing to play by these rules for their spouses, kids or friends!
Should you be one of the lucky ones and the IMR doctor determines that you should get the treatment; then the insurance company must authorize the treatment within 5 business days of receipt of the IMR decision.
However, based on current statistics provided by the State of California, 91% of IMR decisions uphold the UR denial or modification decisions. So you are facing an uphill battle when going to this nameless, faceless anonymous IMR doctor for your final decision on the need for the medical treatment - as, on average, you have only a 9% chance of getting the IMR doctor to agree that you need the medical treatment.
As noted in the discussion of UR in our earlier blog, the treatment guidelines are not black and white, but open to interpretation. It always seems like the doctors hired by Maximus to perform IMR interpret the guidelines in a manner most beneficial to the insurance company; i.e.to save the insurance company money by denying the medical care requested by your doctor. Also, quite often, the insurance company does not comply with the law and send the Maximus all of the documents relevant to the medical treatment request in dispute for the IMR doctor to make a knowing intelligent decision.
If the IMR decision agrees with the UR decision to deny or modify the medical treatment requested for you, you can file a petition appealing the IMR decision to the Administrative Law Judge ('ALJ') within 30 days of your receipt of the decision. If you do not file a petition appealing the IMR decision, then that decision is final. In addition, the UR denial or modification of the medical treatment request will, with limited exceptions, be deemed valid for a full year from the date of the decision without further action by the insurance company.
In our next blog, we will discuss the third part of this process, the filing and pursuit of the petition appealing the IMR decision.
If you have been hurt at work and need assistance with the IMR process or any other aspect of getting medical care, please call us at 866-324-9558. We will be more than happy to discuss your case with you.